Our Returning Veterans, Are We Ready? Brant A. (Bud) Elkind, MS, CBIS-T Director, Clinical Operations Robin Hill Farm, Inc. 11/20/2018

Traumatic Brain Injury (TBI) TBI - “An insult to the brain, not of a degenerative or congenital nature but caused by an external force, that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning” (AACBIS) 11/20/2018

Acquired Brain Injury “An injury to the brain occurring after birth that is not hereditary, congenital or degenerative; does not refer to brain injuries induced by birth trauma” i.e. Stroke/CVA, Anoxia, Disease, Neuro-toxic Poisoning, Metabolic disorders (insulin shock, liver and kidney disease, or trauma (AACBIS) 11/20/2018

Brain Injury Range Mild characteristics include: Loss of consciousness for les than 30 minutes or no loss Glasgow Coma Scale of 13-15 Post-traumatic amnesia for less than 24 hours Temporary or permanently altered mental or neurological state with pos-concussive symptoms (AACBIS) 11/20/2018

Moderate Brain Injury Coma more than 20-30 minutes but less than 24 hours Glasgow Coma Scale or 9-12 Possible skull fractures with bruising & bleeding Signs on EEG, CAT or MRI Scans Some long term problems in one or more areas (AACBIS) 11/20/2018

Sever Brain Injury Coma longer that 24 hours, often lasting day, weeks or longer Coma scale of 8 or less Bruising, bleeding in the brain, signs on EEG, CAT or MRI scans Long term impairment (AACBIS) 11/20/2018

TBI In The United States 1.4 million sustain a TBI each year 50,000 die 235,000 are hospitalized 1.1 million ER visits The number of people who sustain a TBI and do not receive treatment is unknown (BIAUSA) 11/20/2018

Leading Causes of TIB’s Falls 29% Motor Vehicle Accidents 20% (most are unrestrained) Stuck by/against 19% Assaults 11% Other 13% Unknown 9% (BIAA) 11/20/2018

Long Term Consequences of TBI Direct and indirect costs of TBI in the US as of 1995 was estimated at $60 Billion The CDC estimates 5.3 million Americans currently have long term, lifelong need to perform activities of daily living as a result of TBI (BIAA) 11/20/2018

Unmet Need for Services One Year After Injury Improving memory and problem solving Managing stress and emotions Controlling one’s temper Improving one’s job skills (CDC) 11/20/2018

The Wide Range of Functional Change Thinking, language, learning, emotions, behavior and or sensation TBI can also cause epilepsy, increase the potential for Alzheimer’s and Parkinson’s and other brain disorders that become more prevalent with age (CDC) 11/20/2018

OIF – OEF STATISTICS Approximately 1.6 million troops have to date been deployed to Afghanistan and Iraq 300,000 are estimated to have affected by Traumatic Brain Injury (TBI) and or Post Traumatic Stress Disorder (PTSD) 64% of all wounded are estimated to have sustained “Blast Injuries” 47% of all blast injuries affect the head (NABIS) 11/20/2018

Anatomy of a Blast Injury Instantaneous pressure wave with a rise and drop in pressure Results in cavitation occurring at the molecular level ((brain, inner ear, eyes, gastrointestinal tract, lungs and spinal fluid structures are liquefied) Over-pressurization wave dissipates instantaneously creating a vacuum Impact may also energize shrapnel, may exhaust gases and vapors that burn lung tissue and flesh (Wikipedia) 11/20/2018

What We Expect to See as Our Veterans Return Home The most severely injured continue to remain in Poly Trauma Hospitals Those returning with mild brain injuries pose a significant public health concern They will return with high expectations to their homes, families, jobs and communities 11/20/2018

Why there is Reason for Concern Many will return healthy Others will return, unaware of their brain injury (Agnosia, an inability to see their deficits) (D&VBIC) 11/20/2018

What we will see! Difficulty with: Thinking Receptive - Expressive Short – Long-term memory Attention – Initiation Expressive – Receptive Multi-tasking 11/20/2018

What we will see (Continued) Adverse Behavior (Impulsivity, Disinhibition, Anger Control) Seizure activity ETOH – (Alcohol and Substance Abuse) High-risk behavior Disorientation Tinitus and feelings of Isolation (EBIG) 11/20/2018

“Contrary to expectations, patients with mild to moderate TBI are actually much more affected by their emotional difficulties than by their physical disability” (Glasser) Soldiers returning with mild to moderate brain injuries are 3 times more likely to incur a second brain injury and 8 times more likely to incur a third” (CDC) 11/20/2018

Systems of Care Poly-trauma Centers (4) Poly-trauma Network Sites (21) Poly-trauma Support Clinics – VISN (Specialized teams) Poly-trauma Point of Contact 11/20/2018

VA Poly-trauma Rehab System of care Proactive Case Mgt Telehealth Network Long-term follow-up; proactive, specialized Care for those who cannot care for themselves 11/20/2018

So, is the Community Ready Probably not! 5 Professional Brain Injury Programs in NH representing a Continuum Facility based Residential Home based 11/20/2018

Community To welcome our soldiers with mild brain injury home we must be: Inclusive not Integrative Be involved at all levels Social Service Agencies must understand needs Physicians and hospitals must be able to appropriately diagnose, medicate and care for people with mild brain injury 11/20/2018

Other Community Based resources OT’s, PT’s, SLP’s and Psych Professionals must be trained in mild brain injury The community must be knowledgeable in the area of disability rights. 11/20/2018

Partnerships The VA cannot do everything Communities must be willing to include Support systems must be educated and capable to working with this specialized population 11/20/2018

References American Academy for the Certification of Brain Injury Specialists (AACBIS) www.aacbis.net Brain Injury/Professional vol. 4, issue 1, North American Brain Injury Society, “Reintegrating Military Personnel after TBI, Community Integrated Rehabilitation Model in Practice, Trudel, Davanzo, Mattingly, Nideffer & Barth Brain Injury/Professional vol. 4, issue 1, North American Brain Injury Society, Current Trends in Post Traumatic Stress Disorder & TBI among Military Personnel, Nideffer, Errico and Barth The Essential Brain injury Guide, Edition 4.0, American Academy for the Certification of Brain Injury Specialists Blast Injuries, Wikipedia, the Free Encyclopedia, January 2008, NABIS, Blast Injury Institute, Ziejewski, Inz, Karami, Akhatov Defense Veterans Brain Injury Center Brain Injury Association of America, www.biausa.org 11/20/2018